to the editor: We found the article “Vasectomy Techniques” to be an excellent review by Drs. Clenney and Higgins.1 In their description of scrotal incision closure, the authors state that “the incision is closed with absorbable suture.” No reference or alternate techniques are offered. Leaving the scrotal incision open or briefly clamping the scrotal incision may be a superior technique.

A Medline search (1966 to 1999) provided no comparisons of scrotal closure techniques. However, Campbell's Urology2 states, “Suture closure of the scrotal wounds is optional. Leaving the small incision open helps prevent hematoma formation. The wound seals itself in 24 hours.” Additionally, an unpublished review of scrotal closure practices in one community hospital showed no statistical difference and a very low complication rate with all three techniques.3 This review included approximately 150 patients in whom the scrotal incision was left open, 500 in whom scrotal incisions were clamped and 900 in whom scrotal incisions were closed with suture.

Leaving the incision open requires no special treatment other than the normal postoperative scrotal support. The “clamp technique” involves approximating the scrotal incision with the “first click” of a hemostat to lightly approximate the skin for five minutes. These two techniques would save suture cost and time, especially if suture is not required in another part of the procedure.

In summary, leaving the scrotal incision open or lightly approximating the skin with a hemostat may be superior or at least equal to closure with suture. The savings of time, money and possibly a lower hematoma rate make a “no suture” vasectomy closure worth considering.

TROY BOREMA, LT, MC, USN

STEVEN BLIVIN, LCDR, MC, USNR

Family Practice Department

Naval Hospital Jacksonville

2080 Child Street

Jacksonville, FL 32214

The opinions expressed herein are those of the authors and do not necessarily reflect those of the Department of the Navy or the Department of Defense.

to the editor: In their article on vasectomy,1 Drs. Clenney and Higgins show metal clips being placed on the vas deferens for occlusion and reference my article2 in support of this method. In fact, I wrote my article to bemoan the use of clips, and to show how thermal cautery with accurate suture placement to pursestring the vasal sheath can efficiently provide better occlusion and fascial coverage of the prostatic end.

Clips can be used for vasal occlusion and fascial interposition. When one clip on each end is used for vasal occlusion, they have the same 1.0 to 1.5 percent failure rate as all other methods that ligate the vas.3 Occluding the vas is much different than occluding a blood vessel. When a blood vessel is ligated, it clots back to the last branch. When the vas is ligated, transluminal ischemic necrosis occurs at the site of ligation, ultimately leading to a failure of occlusion. I suspect that the only reason the failure rate of vasal ligation technique is so relatively low is the degree of associated surgical trauma and scarring at the site. Moss3 reported a zero percent failure rate using two clips on each end but later abandoned the technique in favor of cautery and fascial interposition.

The late Stanwood S. Schmidt revolutionized the science of vasal occlusion by showing that intraluminal cautery and fascial interposition is nearly failure-proof when performed correctly.4 Red-hot wire thermal cautery inside the prostatic end uses the body's natural fibroblastic response to a third-degree burn to scar the vas closed.4 Accurate fascial interposition using the vasal sheath separates the cut ends in the tissue, thus preventing recanalization. Errey and Edwards,5 and later Moss,6 have shown that leaving the testicular end open greatly minimizes subsequent testicular pain and congestive epididymitis, with no change in failure rate.

I did use clips for fascial interposition during no-scalpel vasectomy for a period of time. I found that they frequently hung up in the narrow tissue tract when I let the vas slide back into its normal anatomic position. This created the dilemma of whether to leave the vas in the wrong plane and possibly cause chronic pain or vasocutaneous fistula, or to pull the vas down by testicular traction and potentially dislodge the clip. Hating this choice, I abandoned clips in favor of suture for the fascial interposition. Because they are hydrolyzed rather than phagocytosed, I find that Vicryl or Dexon suture causes less tissue reaction than the chromic suture recommended by Drs. Clenney and Higgins.

I feel strongly that all vasectomists should use thermal cautery and fascial interposition on the prostatic end and leave the testicular end open. I believe the evidence shows that this is the best way to occlude the vas deferens. When combined with the minimal surgical trauma to intervening tissue offered by no-scalpel delivery of the vas, we approach the ideal vasectomy.

to the editor: I was surprised to read in the recent review “Vasectomy Techniques”1 that the authors have endorsed a return to the older incisional technique for vasectomy. They point out several advantages of no-scalpel vasectomy but mention it only briefly (“the ideal technique”) at the end of their article.

The no-scalpel vasectomy technique was developed by Dr. Shunqiang Li in 1974 and was formally introduced to the United States medical community in 1991.2 No-scalpel vasectomy has several advantages over traditional vasectomy techniques that include fewer complications, an improved method of anesthesia and a shorter recovery time. The technique has gained considerable popularity; nearly one third (29 percent) of vasectomy procedures that were performed in the United States in 1995 used the no-scalpel technique.3 The procedure has been described in detail in this journal4 and is taught at the American Academy of Family Physician's Annual Scientific Assembly.

I have performed 500 no-scalpel vasectomies in my practice. Patients are routinely seen back at one week postsurgery, and the vast majority of patients note minimal, if any, discomfort during that first postoperative week.

I strongly recommend that incisional vasectomy be relegated to the medical history books. Learn the no-scalpel technique. Your patients will thank you.

in reply: Our thanks to Drs. Borema and Blivin, Reynolds, and Noonan for their comments on our article.1 The standard techniques for managing the vasal ends were cited in our article. Because of individual differences in training and experience, we are not surprised that physicians who perform this procedure are often divided on the issue of clipping versus ligation. In his review of vasectomy outcomes, Denniston2 noted two failures among 169 patients (1.2 percent) when clips were used to occlude the vasal ends. This was superior to the 1.6 percent rate of failure reported with ligation in that review. Although the use of clips appears to be well established,3,4 Dr. Reynolds reports anecdotal difficulties with their use in conjunction with no-scalpel vasectomy techniques. In standard vasectomy, we have found clips to be easily applied, and we continue to advocate their use. We agree with Dr. Reynolds's comments regarding the benefits of luminal thermal cautery, fascial interposition, and leaving the testicular end open—all of which were recommended in our article. As to the purported tissue reactivity of chromic versus Dexon or Vicryl suture, we are unaware of any clinical significance.

We understand Dr. Noonan's enthusiasm for the no-scalpel vasectomy technique. However, our article1 was intended to update family physicians on the nuances of standard vasectomy rather than to extol the virtues of standard vasectomy technique over the no-scalpel technique. The standard technique that was described in our article1 can be completed in 20 minutes or less by most physicians and requires no specialized instruments.

To our knowledge, no prospective, randomized clinical trials have compared the no-scalpel vasectomy with standard vasectomy. In a recently published study by Alderman and Morrison,5 the records of 619 patients who underwent vasectomy performed by the same physician were reviewed for complications. In this series, 336 no-scalpel vasectomy procedures (54 percent of the total group) were compared with 283 standard vasectomy procedures (46 percent of the total group). The short-term complication rate was found to be virtually identical between the no-scalpel vasectomy technique (3.9 percent) and the standard vasectomy technique (4.2 percent). Therefore, it seems reasonable to conclude that the claim of “fewer complications” appears to be questionable, at best, in patients who underwent no-scalpel vasectomy.

Drs. Borema and Blivin have raised the issue of skin closure. My review of the relevant literature failed to yield any peer-reviewed data on skin closure. Unreferenced data are cited in their letter that implies no difference in complications with suture closure, clamp technique or leaving the wound open. Given that no clear evidence exists to the contrary, I would agree that closure or clamp technique would be appropriate options. As for leaving the wound open without treatment of any kind, this would seem to violate the basic principles of wound management. I have found that the wound often bleeds unless it is sutured or clamped, and the lack of incisional treatment may cause undue anxiety to the patient or increase the risk of wound infection.

TIMOTHY CLENNEY, LCDR, MC, USN

Naval Medical Clinic

China Lake, CA 93555

JAMES C. HIGGINS, CDR, MC, USN

Naval Hospital

Jacksonville, FL 32214

The opinions expressed herein are those of the authors and do not necessarily reflect those of the Department of the Navy or the Department of Defense.

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